North Carolina Medicaid Provider Services Director

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The North Carolina Medicaid Provider Services Director leads a team accountable for growing positive, long-term relationships with network providers. This role fosters positive provider experiences, ensures accurate and timely provider claims payment, and promotes high-quality care delivery among network providers, ultimately resulting in improved financial and quality performance. This senior market leader will oversee a team of direct and indirect reports responsible for provider relations and training, claims education, provider engagement, and practice transformation.

Key Role Objectives

• Strategic Direction: Set strategic direction for and oversee key business functions, including provider relations and training, claims analysis and education, provider quality, and value-based payment performance.
• Provider Relationship Management: Build and support the development and growth of positive, long-term relationships with a diverse range of network providers (e.g., primary care providers, hospitals, rural health clinics, human services districts, federally qualified health centers, behavioral health providers, long-term care providers, and healthcare systems) to maintain service support excellence and improve financial and quality performance within the contracted working relationship with the health plan.
• Data Analysis & Performance Monitoring: Regularly review data, such as claims denial/rework data and trends, call center data, and provider performance data, to monitor team performance and guide strategic improvements to provider relationships and performance.
• Market Oversight: Provide North Carolina market oversight and governance of provider audits, compliance, provider surveys, provider service and relations, credentialing, contract management systems, and practice transformation.
• Contractual Compliance: Ensure the team's compliance with North Carolina’s Managed Care Contractual requirements for provider relations, including claims dispute resolution within specified timeframes.
• Cross-Functional Collaboration: Work closely with enterprise teams on claims processing, reporting, contracting/credentialing, network adequacy, provider dispute resolution issues, and provider performance tracking and tool enhancements.
• Interoperability & Recruitment: Understand Humana’s interoperability capabilities, drive provider recruitment strategy, and engage in provider recruitment calls.
• Communication & Training: Guide the Provider Services Advisor to plan and deliver regular and ad hoc provider communications and to develop the provider training and education strategy.
• Operational Excellence: Drive performance and develop operational policies and procedures to align with the provider services model and execute strategic initiatives within the provider network.
• Team Development: Conduct regular performance evaluations of employees and provide ongoing feedback and coaching as necessary to achieve service, quality, and production goals. Identify and support professional development for direct and indirect reports to drive exceptional associate engagement and performance.
• Performance Management: Set and monitor team key performance indicators.
• External Representation: Represent Humana at North Carolina Medicaid meetings and participate in, and travel to if needed, key provider meetings and provider association meetings.

Requirements

• Education: Bachelor's degree
• Experience: 8+ years in provider relationship management, provider education,

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